Updates

Sentara Health Plans will apply a claims edit to deny radiology procedure codes requiring anatomical modifiers when the modifier is not submitted on the claim. Without the proper anatomical modifier applied to the procedure code, there is a risk of duplicate claims payment, incorrect procedure-to-procedure bundling, incorrect frequency limitations, and unnecessary medical record review.

MS DRG 870 reports claims for septicemia or severe sepsis with mechanical ventilation greater than ninety-six hours. The edit will deny claims for MS DRG claims when the discharge status is not equal to (02,05,30,82,85) and reports with inpatient procedure code 5A0955A and the length of stay less than 96 hours.

Sentara Health Plans will deny claim lines when two or more of the service codes listed below are billed by the same provider on the same date of service including when modifier 59 is applied.

Effective August 1, 2025, Sentara Health Plans will be deploying an edit that reviews surgical procedures on the foot and toes (code range 28001-28899*) and the hand and fingers (code range 26010-26989*) when they are not reported with the appropriate anatomical modifier.

Effective August 1, 2025, Institutional providers should not have to report on the usage of a no cost item. However, claims providers may be required to bill a no cost item due to claims processing edits that require an item (even if received at no cost) to be billed along with an associated service.

Any notice, request, instruction or other document or correspondence required to be given under the Provider Agreement, if sent by registered mail, overnight delivery or certified mail, or return receipt requested, must be mailed to the following address: Vice President, Network Management Sentara Health Administration, Inc. 1300 Sentara Park Virginia Beach, Virginia 23464.

Effective March 31, 2025, health coaching, authorization support for post-acute care, and sleep services performed by CareCentrix® will be transitioned to Sentara Health Plans. The network for Home Infusion services will transition from CareCentrix network to the Sentara Health Plans network.

According to the ICD-10-CM manual guidelines, some diagnosis codes indicate laterality, specifying whether the condition occurs on the left or right, or is bilateral. The diagnosis-to-modifier comparison assesses the lateral diagnosis associated with the claim line to determine if the procedure modifier matches the lateral diagnosis.

Diabetic shoes and inserts are covered expenses for adults over the age of twenty-one (21) when medically necessary and submitted with an ICD-10 code for Diabetes (ICD-10 E08.00-E13.9).

Provider payment processing is transitioning to the Zelis Payments Network.

OncoHealth will administer Sentara Health Plans' Oncology Benefits Management Program.

The Genetic Testing Management (GTM) program includes new and revised medical policies, a new authorization request process, guidelines, and consistent preservice reviews for certain genetic testing services that will be applicable to both ordering and rendering provider partners.

OncoHealth will administer Sentara Health Plans (SHP) Oncology Benefits Management Program.

Effective January 1, 2025, Quest Diagnostics will become the exclusive independent laboratory vendor for Commercial and Government programs.

Department of Behavioral Health and Developmental Services (DBHDS) is requiring that providers of 23-Hour Crisis Stabilization services obtain one of the following licenses: (i) MH Center-Based Crisis Receiving Center for Adults (02-040) and/or MH Center-Based Crisis Receiving Center Children and Adolescents (02-041). Providers of 23-Hour Crisis Stabilization are required to do all the following actions by December 2, 2024.

Change In Enrollment Policy for Certain Dual Eligible Medicare-Medicaid Enrollees

Sentara Health Plans complies with CMS requirements for the use of modifiers JW and JZ on single-dose container drugs.

Sentara Health Plans does not cover general anesthesia when rendered in place of service 11 (office).